Safety Leadership: Two Tales of One Incident
Qatargas Wins Two Prestigious Awards From the British Safety Council
December 15, 2015
Reflections from the Abu Dhabi International Petroleum Conference and Exhibition (ADIPEC) 2015
February 11, 2016
January 27, 2016
Note: This is Part XV in a series of posts entitled "Evolving Beyond Behaviourism." Read Part XIV here.
A serious injury occurred at a brownfield site in Asia recently. Below are two versions of the incident.
(This blog is based in part on an actual occurrence.)
- A worker fell from a truck bed while performing a routine task. He was not tied-off. His fall was not observed by any colleagues. A grainy, hard-to-interpret security video recording captured the time of the incident and some information about what happened just before the fall. His version of the incident and the statements of his colleagues, talking about what preceded the fall, do not match the video. It appears he reached up from the truck bed and stepped on a pipe support to perform a routine task.
The team did not report the incident for at least 12 minutes. The injured person complained of a sore shoulder and verbally minimized the seriousness of the injury. After some discussion he was taken to the medical center where they found that his neck was broken. The delay in reporting the incident and downplay of the seriousness directly affected the immediate response and care provided to the worker.
The worker had attended a site orientation that included briefing on work-at-height without protection -- harness, railings, etc. “Cardinal” or Life-Saving” rules were promoted, as were the consequences of non-compliance. Regular meetings had recently occurred which discussed work-at-height.
Clearly rules were broken, and it seems likely that there was an attempt to hide the incident.
- Same incident – same observable facts – some additional information:
The worker is from an indigenous group in his native country, as are his workmates and supervisor. They do not speak or read the languages spoken on site. No manager on site speaks their native tongue. His work group is close and look out for each other. There have been no disciplinary or safety problems prior to this incident.
The worker lives all year round in company housing and sends virtually all of his income home to his family. Although there is not a punitive culture on his current job, he and his colleagues have seen bad things happen on previous jobs in the area to both a worker who gets hurt and others who report incidents. They feel lucky to have work on this site. They work hard. They keep quiet. They are accustomed to bumps, bangs and scrapes in their lives.
The injured worker has broken vertebrae; he will recover, though it will take time and it is likely that he will only be able to do limited work and other activities for a long time. His future is very uncertain.
Ok, so you are the HSE Manager assigned to lead the incident investigation or even better: the Sponsor. The following are key questions you would need to consider:
Is this a blatant disregard of the rules which result in dismissal? Clearly “the worker made a bad decision” and so must be held accountable for it. The rules and consequences were clearly communicated.
How do you rectify the disregard of the rules with the apparent good intentions of the worker and his colleagues?
How do you balance the “discipline” needed to support compliance on-site with the harm already done to the worker (and his colleagues)?
Does firing the worker and maybe his supervisor send the right message to the workforce in this case? Would a more nuanced response by the company show weakness?
How could the company show greater “regard” for the teams’ response (instead of judging “disregard” by the worker, his colleagues and his supervisor?
JMJ suggested that perhaps there was a bigger opportunity here. Rather than just reinforcing the rules, what might provide a better overall outcome?
I realize this is not the complete picture of the incident. Many operating and construction sites are not subject to the issues around operating across different languages and cultures or employing resident workers.
But I assert that this anecdote provides a valid example of the complexity of workplaces and incidents not recognized by most companies’ safety credentials, rules and systems. There are too many managers following ‘just cause’ and using their processes and other management playbooks to see what is really happening on site rather than learning from the incidents that occur.
How would you respond?
Where do you stand as regards to errors, blame, learning, discipline, etc., and how do they inform your recommended response? I look forward to your answers and thoughts.
I have addressed the role of Safety Leaders in response to incidents in my previous blogs. In an upcoming one I will summarize the responses I receive and write more on how I believe Safety Leaders need to think, act and behave to shift the culture of safety, and how they can use incidents as a lever for doing so.
Thank you for joining the conversation.
